Endoscopy, in full.

General post-polypectomy surveillance still follows USMSTF 2020 (Gupta et al.), which has not been replaced: 1-2 tubular adenomas <10 mm, 7-10 years; 3-4 tubular adenomas <10 mm, 3-5 years; 5-10 tubular adenomas <10 mm, any adenoma ≥10 mm, or an adenoma with tubulovillous/villous histology or high-grade dysplasia, 3 years; >10 adenomas, 1 year with polyposis evaluation. For serrated polyps: 1-2 SSLs <10 mm, 5-10 years; 3-4 SSLs <10 mm or a hyperplastic polyp ≥10 mm, 3-5 years; an SSL ≥10 mm, an SSL with dysplasia, or a traditional serrated adenoma, 3 years. When findings are mixed, use the shortest interval indicated. Before applying an interval, confirm complete resection and adequate prep. Piecemeal resections get a site check, and malignant (T1) polyps go to a tumor-board pathway. Serrated polyposis syndrome (SPS) is now governed by a separate USMSTF consensus statement (Rex et al., published simultaneously in Gastroenterology, Am J Gastroenterol and GIE on 2026-09-30). It has 11 recommendations. Diagnose SPS with the 2019 WHO criteria, which count the size, cumulative lifetime number and location of serrated polyps. Until SPS is diagnosed, record the number, size and location of serrated polyps in every colonoscopy report. SPS colonoscopy should be done by endoscopists with documented adequate SSL detection, using high-definition white light with or without chromoendoscopy. Without concurrent CRC, endoscopy is preferred over surgery for primary management. If the polyp burden cannot be managed endoscopically, refer to an advanced endoscopic resection expert before surgery. Resect SSLs and hyperplastic polyps by cold snare, with submucosal injection for larger lesions. Do clearance colonoscopy at 3-6 months, then surveil every 1-2 years. Consider 3-year intervals if the burden is greatly reduced at surveillance. First-degree relatives start colonoscopy at age 40, or 10 years before the youngest CRC diagnosis in the family, or 5 years before the youngest SPS diagnosis, whichever comes first. SPS has no established genetic basis, so germline testing is recommended only when concurrent non-serrated polyps suggest a heritable syndrome. Lynch, FAP/AFAP and MAP criteria still trigger genetic evaluation.

WORKUP (NCCN ESOPH-1): H&P; EGD with biopsy; chest/abdomen CT with oral and IV contrast; pelvis CT with contrast ONLY as clinically indicated; FDG-PET/CT (skull base to mid-thigh) if no evidence of M1 disease; CBC and comprehensive chemistry; EUS if no evidence of M1 or unresectable disease; endoscopic resection (ER) is recommended for accurate staging of early-stage cancers (Tis, T1a, or T1b) and may also be therapeutic; bronchoscopy if the tumor is at or above the carina with no evidence of M1; biopsy of metastatic disease as clinically indicated; assign Siewert category; nutritional assessment and counseling; smoking-cessation counseling; screen for family history. BIOMARKERS: universal MSI (PCR/NGS) or MMR (IHC) testing AND universal PD-L1 testing in ALL newly diagnosed patients; HER2 and CLDN18.2 testing if advanced/metastatic adenocarcinoma is documented or suspected; NGS should be considered. Multidisciplinary evaluation is recommended for stage I-IVA (locoregional) disease (ESOPH-E). ENDOSCOPIC THERAPY (ESOPH-A): the goal of endoscopic therapy (EMR, ESD, and/or ablation) is complete removal or eradication of early-stage disease, pTis, pT1a, and SELECTED superficial pT1b without LVI, plus the pre-neoplastic Barrett's segment. Tis/HGD must first be fully characterized for nodularity, lateral spread and multifocality, with EUS to rule out nodal metastases in select higher-risk cases. Areas of nodularity or ulceration must be RESECTED, not ablated. Completely flat lesions ≤2 cm (squamous HGD/Tis, and BE with flat HGD) should be treated by ER because it gives more accurate histologic assessment; flat lesions >2 cm can be treated by ER but with greater complication risk, and may be treated by ablation alone (data for ablation-alone in squamous HGD are very limited). Lesions pathologically limited to lamina propria/muscularis mucosae (pT1a) or superficial submucosa (pT1b), in the absence of nodal metastases, LVI, or poor differentiation, can be treated with full ER, HOWEVER a thorough patient-and-surgeon discussion of esophagectomy versus the risk of concurrent nodal disease should be undertaken, especially for larger tumors or deeper invasion. Ablation of residual Barrett's should follow ER; complete BE eradication may also be achieved by widefield EMR or ESD at the initial intervention when needed to resect superficial tumor or nodularity ≤2 cm. For SCC, the level of evidence for ablation after ER is LOW; additional ablation may be needed only for multifocal HGD/CIS elsewhere, and may not be needed for completely excised lesions. Endoscopic therapy is 'PREFERRED' for limited early-stage disease: Tis and T1a, ≤2 cm, well or moderately differentiated. Esophagectomy is indicated for extensive carcinoma in situ (pTis/HGD), pT1a, or superficial pT1b, especially nodular disease not adequately controlled endoscopically. PRIMARY TREATMENT, MEDICALLY FIT PATIENTS, ADENOCARCINOMA (ESOPH-13): cT1b-cT2, N0 LOW-RISK (<3 cm, well differentiated) → esophagectomy. cT2 N0 HIGH-RISK (LVI, ≥3 cm, or poorly differentiated), cT1b-cT2 N+, or cT3-cT4a any N → perioperative systemic therapy is PREFERRED (FLOT: 5-FU 2600 mg/m2 IV over 24 h day 1, leucovorin 200 mg/m2, oxaliplatin 85 mg/m2, docetaxel 50 mg/m2, every 14 days, 4 cycles pre- and 4 cycles postoperatively; or FLOT + durvalumab 1500 mg for PD-L1 CPS ≥1 or TAP ≥1%, category 1 for EGJ, category 2A for esophageal adenocarcinoma; note MATTERHORN showed no EFS advantage for durvalumab in diffuse-type disease), QUALIFIER: perioperative therapy is preferred for patients medically fit and with access to frequent toxicity evaluation; preoperative chemoradiation for planned esophagectomy remains an option and may be considered for borderline-resectable patients or patients who are not FLOT candidates (perioperative FOLFOX/CAPOX is another alternative). Consider neoadjuvant or perioperative immune checkpoint inhibitor if the tumor is MSI-H/dMMR (in multidisciplinary consultation; the role of surgery after complete response is unclear). Definitive chemoradiation for patients who are medically unfit/inoperable for surgery or who decline surgery. cT4b → definitive chemoradiation, or chemotherapy alone with invasion of trachea, great vessels, vertebral body, or heart. SQUAMOUS CELL CARCINOMA (ESOPH-2): cT1b-cT2, N0 LOW-RISK (<3 cm, well differentiated) → esophagectomy (non-cervical esophagus). cT2 N0 high-risk (LVI, ≥3 cm, poorly differentiated), cT1b-cT2 N+, or cT3-cT4a any N → PREOPERATIVE CHEMORADIATION is preferred (or definitive chemoradiation). cT4b → definitive chemoradiation, or chemotherapy alone for trachea/great-vessel/vertebral/cardiac invasion. NCCN states explicitly: 'Preoperative chemoradiation is preferred for esophageal SCC.' Preoperative RT dose 41.4-50.4 Gy at 1.8-2.0 Gy/day (23-28 fractions); preferred concurrent regimens include weekly paclitaxel 50 mg/m2 + carboplatin AUC 2 (CROSS, category 1) and fluorouracil + oxaliplatin (category 1). POSTOPERATIVE (ESOPH-F): nivolumab is the preferred postoperative regimen ONLY after PREOPERATIVE CHEMORADIATION with R0 resection and residual pathologic disease (category 1), 240 mg IV every 14 days for 16 weeks, then 480 mg IV every 28 days, maximum treatment duration 1 year. PALLIATION (ESOPH-A/H): esophageal dilation with balloons or bougies for temporary relief of malignant or treatment-related obstruction (avoid overdilation, perforation risk); long-term dysphagia palliation by endoscopic tumor ablation (Nd:YAG laser, PDT, cryoablation) or expandable metal/plastic stents; feeding gastrostomy or jejunostomy for anorexia/dysphagia/malnutrition, but placement of a GASTROSTOMY preoperatively may compromise the gastric vasculature and interfere with gastric-conduit reconstruction and SHOULD BE AVOIDED (feeding jejunostomy is generally preferred for postoperative nutritional support; multidisciplinary expertise is recommended before percutaneous gastrostomy).

Diagnose acute pancreatitis (AP) by the Atlanta criteria (2 of 3: characteristic epigastric/LUQ pain, lipase or amylase >3x ULN [lipase preferred for specificity/duration], or characteristic imaging). ACG 2024 stratifies severity risk using SIRS on admission plus bedside risk factors, rising/elevated BUN, rising/elevated hematocrit (>44), obesity (BMI>30), extrapancreatic fluid collections/pleural effusion/infiltrates, altered mental status, and older age/comorbidities, rather than mandating a formal BISAP or APACHE II composite score. Give moderately aggressive lactated Ringer's, most important in the first 6-12 hours, reassessing volume status/BUN/HCT at 6 hours (further aggressive hydration has little added benefit after 24-48h). Start oral low-fat solid food within 24-48h as tolerated in mild disease; if enteral feeding is needed for moderately severe/severe disease, prefer nasogastric over nasojejunal with small-peptide/medium-chain-triglyceride formula and continuous (not bolus/cyclic) feeding; avoid parenteral nutrition if possible. Do not give prophylactic antibiotics, even in severe disease or sterile necrosis; reserve antibiotics for suspected infected necrosis (typically arising 10-14 days in), and choose agents that penetrate pancreatic necrosis while together covering both gut-derived gram-negative enterics and anaerobes, a carbapenem supplies this as monotherapy, whereas a fluoroquinolone or a third-or-higher-generation cephalosporin must be combined with metronidazole; metronidazole alone (anaerobic cover only), or a cephalosporin or a quinolone alone, does not adequately treat infected necrosis. Perform cholecystectomy preferably before discharge for mild acute biliary pancreatitis, and after a second unexplained AP episode even without identified gallstones; reserve ERCP within 24h for AP complicated by cholangitis, with rectal indomethacin +/- pancreatic duct stent and periprocedural hydration to reduce post-ERCP pancreatitis risk. Check triglycerides when gallstones/alcohol are absent (>1000 mg/dL supports a hypertriglyceridemia etiology). For stable pancreatic necrosis, defer surgical, radiological, or endoscopic intervention 4-6 weeks to allow walling-off (step-up approach).

Confirm peptic ulcer disease with EGD, biopsy all gastric ulcers to exclude malignancy, and test every PUD patient for H. pylori. In ulcer bleeding, risk-stratify pre-endoscopy with the Glasgow-Blatchford score (GBS ≤1 may be managed as an outpatient), resuscitate with crystalloid, and transfuse restrictively in hemodynamically stable patients with no history of cardiovascular disease (transfusion threshold hemoglobin ≤7 g/dL, post-transfusion target 7-9 g/dL); in hemodynamically stable patients with a history of acute or chronic cardiovascular disease use a more liberal strategy (transfusion threshold ≤8 g/dL, post-transfusion target ≥10 g/dL); the restrictive strategy applies only to non-massive bleeding, so in exsanguinating or hemodynamically unstable hemorrhage transfuse based on hemodynamics and ongoing blood loss rather than waiting for a hemoglobin threshold. Perform endoscopy within 24 hours of presentation; emergent (≤6 h) or urgent (≤12 h) endoscopy is NOT recommended unless the patient remains hemodynamically unstable despite adequate resuscitation. Give pre-endoscopy IV erythromycin (IV metoclopramide if erythromycin is unavailable, in clinically severe or ongoing active bleeding); pre-endoscopy high-dose IV PPI may be considered but must not delay endoscopy. Treat by Forrest class: Ia/Ib get combination therapy (dilute epinephrine injection plus a second modality, contact/noncontact thermal or mechanical TTS/OTS clip), with over-the-scope clip monotherapy now an accepted first-line alternative to combination therapy given its lower rate of further bleeding, and hemostatic forceps with soft coagulation a further alternative; IIa (nonbleeding visible vessel) gets thermal, mechanical (TTS or OTS clip), or sclerosant injection as monotherapy or combined with epinephrine; IIb (adherent clot) gets clot removal with treatment of underlying stigmata where the endoscopist is technically competent to manage conversion to a higher-risk lesion; IIc/III (flat spot, clean base) get no endoscopic therapy and may be discharged early on oral PPI. Epinephrine injection must never be used as monotherapy, and topical hemostatic agents must not be used as first-line monotherapy (they are reserved, with OTS clips, for bleeding refractory to standard modalities). After hemostasis, give high-dose PPI as 80 mg IV bolus then 8 mg/h infusion for 72 hours (twice-daily IV bolus or twice-daily oral high-dose PPI are acceptable alternatives); the same applies to untreated FIIb clot. Routine second-look endoscopy is not recommended. For recurrent bleeding, repeat endoscopy and consider an OTS clip if not already used; if the second attempt fails, proceed to transcatheter angiographic embolization (TAE), with surgery when TAE is unavailable or unsuccessful. Prophylactic TAE may be considered in selected high-risk cases (hemodynamic instability at presentation, posterior duodenal wall ulcer, ulcer >2 cm, or uncertain durability of hemostasis). Start clear liquids/early oral nutrition within 24 hours of durable hemostasis, and initiate iron therapy before discharge for iron deficiency and/or anemia. Resume anticoagulation as soon as clinically indicated based on thromboembolic risk, resume aspirin for secondary prevention within 24 hours, and give PPI co-therapy to patients continuing DAPT or anticoagulation after a bleed. Test for H. pylori at the index endoscopy and treat if positive; retest patients testing negative acutely (a false-negative is common in the bleeding setting), holding PPI at least 2 weeks before retesting, and document successful eradication in every treated patient. For eradication, first-line therapy in treatment-naive patients with unknown susceptibility is optimized bismuth quadruple therapy for 14 days (PPI twice daily, tetracycline 500 mg four times daily, metronidazole 500 mg three to four times daily, bismuth four times daily); rifabutin triple therapy or vonoprazan-amoxicillin dual therapy for 14 days are acceptable empiric alternatives in patients without penicillin allergy. PPI-clarithromycin triple therapy and levofloxacin-based regimens are recommended against unless susceptibility testing proves the organism is sensitive. Salvage therapy in treatment-experienced patients is optimized bismuth quadruple therapy for 14 days if not previously used, otherwise a susceptibility-guided or non-cross-resistant regimen. Test of cure is required in ALL treated patients by urea breath test, fecal antigen, or biopsy-based test at least 4 weeks after completing antibiotics and at least 2 weeks off PPI. Heal ulcers with PPI (duodenal ulcer 4 weeks, gastric ulcer 8 weeks, with repeat EGD at 8-12 weeks to confirm healing and exclude malignancy), discontinue or mitigate NSAIDs with long-term PPI or PCAB co-therapy if NSAIDs must continue, maintain long-term acid suppression in idiopathic (H. pylori-negative, NSAID-negative) ulcers, and pursue gastrinoma/ZES or refractory-ulcer workup in H. pylori-negative/NSAID-negative or non-healing cases.